Chinese Liver Fluke (Clonorchis Sinensis)

Group members: Nattakorn Masaya-anon (Khing), Kittiya Luealamai (Por), Konrapee

Panyanak (Toon), Nutticha Kaewthong (Natt)
1. Overview of Situation & Response
Clonorchiasis is a disease in human caused by the parasite Clonorchis Sinensis
or Chinese Liver Fluke, which lives in the bile duct or gallbladder and feed on
bile. More than 30 million people with 85% of the cases in China and most of the
remaining ones in Southeast Asia. People in northern of Thailand rely heavily on water.
The main sources of food come from river and forest. This agrees with the fact that
young liver flukes use snail in the forest and fish in rivers as intermediate hosts to
develop larvae and encysting. The fluke then enters principle(mammals) host body
when they ingest the intermediate hosts. Therefore, we aimed to offer them a program
of treatment and prevention to the local communities of Northern Thailand. The
program will include both treatment using drugs such as Praziquantel (PZQ) and
Abendazole which effects on the function of worm’s sucker, and a prevention measures
such as limiting parasite intake, set-up water filtration system and educating the locals
to stop further outbreak. These programs will cost 1000 baht per person. Immediate
response will cost 253,000 baht from the government, but if we delay it for 3 months,
the cost can reach up to 624,000 baht, according to the estimated number of patients.

2. Situation
2.1 Organism (Identification, habitat, life cycle)
2.1.1 Identification
Phylum: platyhelminthes
Class: trematode
Family: opisthorchiidae
species: Clonorchis Sinensis

2.1.2 Habitat and Characteristics

Young liver fluke use immediate host in water like snail and fish
to develop their larvae, and then use principle host, which is mammals to
develop adult fluke. Adult flukes have sexual reproduction in principle host
in bile duct, gallbladder, lumen in intestine, etc. All of these are connected
to passage way out of our body. Eggs of adult fluke exit body and live in
water. Once they are hatched, and became miracidium - a free moving
ciliated larvae stage fluke, they have to find a snail within 2 hours. Inside
of snail, they develop into sporocyst - an encysted zygote, and turn into a
redia. Redia eventually become cercaria, and swim out of snail to find
another intermediate host, which is fish. In this process, they have 48 hours
to find a fish, encysted in the fish muscle by using its oral sucker.
Additionally, water plants are also a common host too. People usually get
cercaria through water. It’s not dangerous to ingest this stage of larvae, still,
we should educate them about how to find, or make a clean source of water.
In fish muscle, they develop 4 layers of metacercarial cysts. The most outer
layer, layer 1 appears as a thin fibrous capsule, and seems to be produced
 by surrounding host tissue. The infected fish swims slower, easy to be
catch by a bird or human. In case of human, gastric juice in stomach will
digest the capsule of metacercarial cyst, causing the fluke inside to exits
and develop to be an adult fluke in human body. Then they have sexual
reproduction, their eggs exit our body, and the cycle repeats.

2.2 Area
Clonorchis Sinensis infection is currently outbreaking in a community in
northern Thailand. The area can be considered a countryside, whereas it holds
10,000 numbers of people in the population. One-third of the people there earn
their living on agriculture, by farming cows, pigs, sheep, and export them to cities.
On the other hand, they mainly rely themselves on freshwater fish and mollusks
which they obtain from rivers--noting that rivers and stream are prevalent in the
area and are fundamental as water sources for the villagers. For fauna and flora in
the area, there are surrounding mixed forests being a habitat for various types of
mammals, reptiles, and mollusks e.g. rats, dog, mice, bats, snakes, skinks, snails,
etc.
However, the area has several limitations that affect the spread of the
epidemic: even though the community has good law enforcement, the sanitation
is poor and as no system is provided; local hospitals can supply limited room for
patients, and mass transit does not exist. That’s restrict people’s opportunity to
move into a city and receive a better treatment to the disease, while the main cause
of it is their food, fish from the rivers and sources of parasites.

2.3 Situation
2.3.1 Initial Conditions
The first clonorchis sinensis
infection incidence in the area
emerged in September the
previous year. Then both the
number of new cases and
accumulative number of patients
rise virtually exponentially. The
disease growth rate is shown in the
table on the right:

2.4 Health
2.4.1 Signs and Symptom
The intake of clonorchis sinensis or Chinese liver fluke parasite can lead
to numbers of diseases in hepatic and biliary systems, and cause inflammation
in the liver, gallbladder, and biliary tract. The infection is more frequently
asymptomatic until the number of flukes exceeds thousands. Anyone diagnosed
 with Chinese liver fluke is likely to have problems digesting fat because the
bile, which breaks down fats, is being consumed by the parasite. An adult
Sinensis can consume all the bile from its host, inhibiting the entire digesting
process. For mild infections, the signs and symptoms include fever, chill,
epigastric pain (below libs and in upper abdomen), tender hepatomegaly
(swollen liver), jaundice (yellow skin because of the excess production of
bilirubin), eosinophilia (excess eosinophil in white blood cells causing
inflammation), and diarrhea. For severe infections, the signs and symptoms are
the same with the addition of liver atrophy and chronic clonorchiasis (chronic
inflammation). After a prolonged infection, clonorchis sinensis can cause
cancer in the liver and bile duct, which is fatal.
2.4.2 Prognosis
If the disease is untreated, it may sustain up to 25-30 years, as long as
the lifespan of the parasite. The disease has high tendency to be undiagnosed
in the early state, but as the flukes thrive, the situation aggravates and develop
several more related diseases as mentioned above. The condition may also
develop into chronical disease as well.
3. Response
3.1 Health
3.1.1 Organism Control
In order to control the spread of the disease, we must try to decrease and limit
the chances that the parasite will come in contact with and enter the bodies of the
population at risk. This parasite comes with raw or undercooked fish and snails,
which are eaten in Northern Thailand. Their cuisine includes salted, smoked, and
pickled fish, and occasionally snails. Therefore, we will split into small teams to
educate people in all sub-communities on how to cook them properly. Until that task
is accomplished we will prohibit the consumption of those two carriers, and provide
substitutes if needed.
Clonorchis infection usually does not result from drinking river water because
the larvae cannot live in the river without a host. However, setting a water filtration
system for drinking water will ensure less chances of parasite consumption and
improve the sanitation and wellness of the people in the area in general. It is non-
communicable. Therefore, the movements of people from one area to the other do
not contribute to the outbreak, which mean we do not have to limit the local
transportation.

3.1.2 Care for the Sick

We will provide Praziquantel (PZQ) for the sick. It was approved for medical
use in the United States in 1982 and is a medication that can be used to treat
Clonorchiasis brought on by the parasite Clonorchis sinensis. It works partly by
affecting the function of the worm's sucker, and is taken by mouth 3 times a day.
According to the World Health Organization, it is one of the most effective and safe
medicines. However, it also has side effects including poor coordination, abdominal
pain, vomiting, headache, and allergic reactions. While it may be used during
pregnancy, it is not recommended for use during breastfeeding.
 Another possible drug for curing, in case we run out of Praziquantel, is
Abendazole. However, Abendazole is not confirmed in as many areas as
Praziquantel to be completely safe, so it is our second choice. While there is no
guarantee whether or not it can be used during breastfeeding, it should not be used
with pregnant women and we have to obtain a pregnancy test in women of
reproductive potential prior to therapy. We also have to monitor the patients’ blood
counts and liver enzymes (transaminases) at the beginning of each 28-day cycle of
therapy.
Other drugs, such as pain relievers, may be used to treat some of the symptoms
such as pain and diarrhea. Surgery may be necessary in rare cases where cholangitis,
an infection of the bile ducts in the liver, has developed.

3.2 Projections
The number of new cases and the accumulative number of patients can be
projected based on the existed incidences. There are 3 sets of data: the data in case of
no response, the data in case of immediate response, and the data with three months’
later response. The first three graphs below display the projection of number of new
cases in different conditions:
 It can be estimated that, without immediate response, the number of new cases
will keep rising up to 85 cases a month in September and even more in the next month.
On the other hand, the number of new cases will decrease to 0 within only four
months; that means we can end the epidemic in August. If we respond in three months’
time, the number of new cases will increase to the maximum of 72 cases a month in
July and then diminish down to 0 in March in the following year. It takes seven more
months to stop the epidemic which is longer than time taken in case of an immediate
response; as a result, taking an immediate response is the fastest way to restrain the
spread of the disease.
Another data derived is the accumulative number of patients in all three
conditions; they are shown in the graph below:
 The first two graphs show that: without any response, the total number of
patients will thrive at an exponential rate with no clue of declining, reaching 562 cases
in September. It is very likely that all 10,000 villagers will be infected within five
months onwards; contrarily, it can be cut down to 253 in September and kept stable
on the condition that an immediate response is taken. Meanwhile, the total number of
patients will ascend up to 624 cases in March the next year before it maintains stable
if response is taken three months later. It is obvious that the number of patients can be
reduced by almost one-third with the immediate response comparing to the three-
month-later response. Thus, taking an immediate response will best minimize the total
number of victims from the disease.

3.3 Cost
It is pre-calculated that it will cost 1,000 baht per individual for his treatment in
order to maintain good health again. With immediate response, the total cost for the
treatment that the government has to pay will be 253,000 baht, according to the
estimated number of patients; however, it can reach to 624,000 baht if the response is
delayed by three months. Apparently, immediate response is significantly less
expensive and will help save the government revenue in this epidemic control.
In conclusion, taking immediate response is definitely more effective as it ends
the epidemic faster by lower the rate of new cases to zero within four months,
minimizes the number of patients, and saves the treatment cost the most. Therefore,
we strongly suggest that and the organization respond to this epidemic as soon as
possible.

4. Prevention
4.1 measure #1: Bio, Chem
1. Serological - Very helpful method for the diagnosis of Clonorchiasis. It’s a type of antibody
/ antigen that can be detected for a serum samples. Detection of the specific antibody is more
often applied than the antigen due to the trace amount of antigen present and sensitivity
limitations. Regarding a source and standardization of crude extract, many purified
recombinant protein from the tegument or the excretory proteins.
4.2 measure #2: Economic, Political
4.2.1 Economic
Examination can cause the most beneficial confirmation for diagnosed.
Stool examination an option that is inexpensive and does not require the use of
sophisticated equipment. This option gives an easier access to a people that have
less money to afford.
4.2.2 Political
We should have a government to be a group of people who can lead citizens to
avoid Clonorchiasis, If we only do the campaign to stop fishing, some of people who
have no knowledges might not engage. Therefore, government should legislate an
official agreement related to a fishery that people who lived nearby imperiled areas are
not allowed to catch marines until we are free from Clonorchiasis. During the law
processing, government should find a place to explain cause and symptoms of diseases
and send a letter to every houses about the knowledge Clonorchiasis to make sure that
everyone would be safe. In addition, there should be a policy enacted to encourage
people to undergo an annual health check up, so that disease is detected since an early
state and emergency response can be carried out in time.

4.3 Education
After providing the locals with knowledge as to why consumption of raw fish
and snails can be dangerous, we will educate them on an equally important issue,
which is how to prepare them properly.
For fish, the FDA recommends the following for fish preparation or storage to
kill parasites: Cook fish adequately (to an internal temperature of at least 145° F
[~63° C]), or freeze at -4°F (-20°C) or below for at least 7 days (total time); or at -
31°F (-35°C) or below until solid, and storing at -31°F (-35°C) or below for a least
15 hours; or at -31°F (-35°C) or below until solid and storing at -4°F (-20°C) or
below for at least 24 hours.
For snails, always wash hands before and after touching snails and wear gloves
while touching them, and always thoroughly
There should be no consumption of raw vegetables and drinking of unfiltered water.
5. Conclusion
In summary, clonorchiasis or an infection from parasite Chinese liver fluke
(clonorchis sinensis) is currently spreading in the area. The number of new
incidences and total patients keeps rising at a high rate. It is caused by the ingestion
of metacercariae of the parasites via raw fish, snails, and some vegetable. The flukes
seize those as their secondary intermediate hosts, and the consumption of uncooked
fish like the traditional salt, smoke, or pickle fish brings about a high possibility of
infection, as flukes are not exterminated. The fluke then take hepatic biliary tract as
their habitat in human host and start duplicating, aggravating the organ and obstruct
the system. As a result, the immediate response is urgently needed. The first
response to be taken is the restriction of raw fish consumption as well as giving
essential medication. For the dietary problem, the emergency response team will
clarify the situation and provide correct understanding about ways to properly cook
fish to prevent further spreading; simultaneously, substitutes protein source like
meat and bean will be supplied until we make sure that fish are well cooked and
free from parasite. At the same time, PZR - effective medicine for clonorchiasis
treatment - will be immediately distributed to the patients; close care will be taken
in order to avoid complication of the disease. Besides the immediate response, long
term actions are also necessary for disease prevention in a long run. First, the local
hospitals are suggested on monitoring patients as well as healthy people of an
infection through serological test or blood serum examination. Early detection in
patients will result in effective treatment on time and meliorate the effect. Stool
examination is an alternative for lower cost, and these examination should be
included in an annual check up for villagers. Second, the importance of the issue
with the knowledge of ways to prevent it should strongly be communicated. The
emergency response team will separate to divulge information to every part of the
area in urgency; we will teach them to cook and store fish and snail with proper
temperature. Still, it is insisted that local leaders and municipal department keep
reminding their people through media and more importantly through education - in
school for young people and in the community’s center for adults. Regular health
check up is also essential; thus, the government ought to put more revenue in
developing local hospital to have sufficient basic needs, too. In addition, laying a
water filtration system is encouraged as it will prevent any other pathogen infection
in the future.
Last but not least, we, the emergency response team, strongly recommends that all
the action elaborated be carried out and supported by the agency. We aim at saving
people’s lives and hope that the government see the essence of the immediate
response.
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